Patient Registration Form

Highlands Dermatology

Please correct the errors described below.

PATIENT NAME

ADDRESS

EMERGENCY CONTACT

Responsible Party

If Other, please complete this section

INSURANCE INFORMATION

If "No" please note that payment is expected as services are rendered.
If "Yes" Please Upload a picture of your card and complete the following Section

    Please upload a file

    If insured person is other than the patient please complete the following:

    CONSENT FOR TREATMENT

    I consent to the care and treatment by Dr. Cabiran, Jane Pressler FNP-DC,and or Rachael Feibleman FNP. The treatment may include but is not restricted to medications, anesthesia, surgical and invasive procedures, lab, x-ray, or other studies that may be helpful in the performance of the patients care.

    By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

    ASSIGNMENT OF BENEFITS AND GUARANTEE OF ACCOUNT

    I acknowledge full financial responsibility for any services rendered and I understand that the payment of charges incurred in this office is due at the time of service. I also understand that I am financially responsible for all co-payments and any charges that are not paid my insurances. I authorize payment directory to Dr. Cabiran, Jane Pressler FNP-DC and/or Rachael Feibelman FNP, for all medical or surgical benefits otherwise payable to me under the terms of my insurance. In the event an account is turned over to a collection agency, I agree to pay all cost of collection including reasonable attorney’s fees and hereby waiver all rights of exemption under the constitution of the State of North Carolina/Georgia. I certify the information I have reported with regard to my insurance coverage is correct.

    By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

    Exposure to Disease

    I understand that if my provider(s), or any person employed by or under the direction and control of my provider(s), is directly exposed to my body fluids in any manner which may, according to the current guidelines of the Centers for Diseases Control, transmit the Human Immunodeficiency Virus (HIV) or Hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or Hepatitis B or C viruses. I futher understand that by law I am deemed to have consented to the release of these test results to those who were exposed to my body fluids.

    By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

    MEDICAL HISTORY

    Please list ALL prescription medication that you are currently taking:

    Please include strength and how often you take the medication

    Add another medication

    Allergies

    Add new row

    Do you have a family history of the following?

    Please answer to the following questions to comply with the Medicare EHR incentive Program.

    By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

    Your information will be encrypted.

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